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Objective: To examine geographic variation in preventable hospitalizations among Medicaid/CHIP-enrolled children and to test the association between preventable hospitalizations and a novel measure of racialized economic segregation, which captures residential segregation within ZIP codes based on race and income simultaneously. Data Sources: We supplement claims and enrollment data from the Transformed Medicaid Statistical Information System (T-MSIS) representing over 12 million Medicaid/CHIP enrollees in 24 states with data from the Public Health Disparities Geocoding Project measuring racialized economic segregation. Study Design: We measure preventable hospitalizations by ZIP code among children. We use logistic regression to estimate the association between ZIP code-level measures of racialized economic segregation and preventable hospitalizations, controlling for sex, age, rurality, eligibility group, managed care plan type, and state. Data Extraction Methods: We include children ages 0-17 continuously enrolled in Medicaid/CHIP throughout 2018. We use validated algorithms to identify preventable hospitalizations, which account for characteristics of the pediatric population and exclude children with certain underlying conditions. Principal Findings: Preventable hospitalizations vary substantially across ZIP codes, and a quarter of ZIP codes have rates exceeding 150 hospitalizations per 100,000 Medicaid-enrolled children per year. Preventable hospitalization rates vary significantly by level of racialized economic segregation: children living in the ZIP codes that have the highest concentration of low-income, non-Hispanic Black residents have adjusted rates of 181 per 100,000 children, compared to 110 per 100,000 for children in ZIP codes that have the highest concentration of high-income, non-Hispanic white residents (p < 0.01). This pattern is driven by asthma-related preventable hospitalizations. Conclusions: Medicaid-enrolled children's risk of preventable hospitalizations depends on where they live, and children in economically and racially segregated neighborhoods--specifically those with higher concentrations of low-income, non-Hispanic Black residents-are at particularly high risk. It will be important to identify and implement Medicaid/CHIP and other policies that increase access to high-quality preventive care and that address structural drivers of children's health inequities. KEYWORDS child and adolescent health, CHIP, health care disparities, health equity, index of concentration at the extremes, Medicaid, racial/ethnic differences in health and health care, racialized economic segregation, social determinants of health What is known on this topic * Little evidence exists on the importance of where children live for their access to and quality of health care in Medicaid and the Children's Health Insurance Program (CHIP). * High rates of preventable hospitalizations may be indicative of poor access to high-quality outpatient care, but little research has examined preventable hospitalizations among Medicaid/CHIP-enrolled children. * Studies examining preventable hospitalizations have focused on adult populations, are often limited to one state, and have not considered the effects of segregation based on both racial and economic privilege. What this study adds * We assess ZIP code level patterns of preventable hospitalizations for over 12 million Medicaid/CHIP-covered children across 24 states and document considerable across- and within-state variation. * We find a strong association between ZIP code-level racial and economic privilege, using an Index of Concentration at the Extremes measure for racialized economic segregation, and preventable hospitalizations among children. * Our findings demonstrate the need for tailored policy changes within Medicaid/CHIP, and investments to address structural inequities related to segregation, to improve outcomes for children living in less privileged neighborhoods., 1 | INTRODUCTION Children who live in different neighborhoods across the United States face different conditions of daily life and have different access to the resources they need to thrive, [...]

Objective: To compare access at community health centers (CHCs) vs private offices (non-CHCs) under the Affordable Care Act. Data Source: Ten state primary care audit conducted in 2012/2013 and 2016. Study Design: CHCs and non-CHCs were called. We calculated difference in differences comparing CHCs vs non-CHCs by caller insurance type. Principal Findings: In both rounds, Medicaid and uninsured callers had higher appointment rates at CHC than non-CHCs. CHC appointment rates significantly increased between 2012/2013 and 2016 for both employer-sponsored and Medicaid callers, with no significant wait time changes. Appointment rates increased (13.5% points, P < 0.001) and wait times decreased (-5.7 days, P = 0.017) at CHCs relative to non-CHCs for employer-sponsored insurance. Conclusion: Appointment availability at CHCs improved after ACA implementation, without increased wait times. KEYWORDS access, Affordable Care Act, community health centers, 1 | INTRODUCTION Community health centers (CHCs) specialize in delivering care to populations that are predominantly low income and enrolled in Medicaid or uninsured. (1) Expanded access to CHCs has [...]

Objective. To examine the impact of a 2007 redesign of West Virginia's Medicaid program, which included an incentive and 'nudging' scheme intended to encourage better health care behaviors and reduce Emergency Department (ED) visits. Data Sources. West Virginia Medicaid enrollment and claims data from 2005 to 2010. Study Design. We utilized a 'differences in differences' technique with individual and time fixed effects to assess the impact of redesign on ED visits. Starting in 2007, categorically eligible Medicaid beneficiaries were moved from traditional Medicaid to the new Mountain Health Choices (MHC) Program on a rolling basis, approximating a natural experiment. Members chose between a Basic plan, which was less generous than traditional Medicaid, or an Enhanced plan, which was more generous but required additional enrollment steps. Data. Collection. Data were obtained from the West Virginia Bureau for Medical Services. Principal Findings. We found that contrary to intentions, the MHC program increased ED visits. Those who selected or defaulted into the Basic plan experienced increased overall and preventable ED visits, while those who selected the Enhanced plan experienced a slight reduction in preventable ED visits; the net effect was an increase in ED visits, as most individuals enrolled in the Basic plan. Key Words. Medicaid reform, ED visits, personal responsibility, Mountain Health Choices, Rising health care costs and increased enrollment place pressure on state Medicaid programs and budgets. (1) A particular concern for cost containment in Medicaid has been the rising rate of [...]

Objective. To assess the effects of past Medicaid eligibility expansions to parents on coverage, access to care, out-of-pocket (OOP) spending, and mental health outcomes, and consider implications for the Affordable Care Act (ACA) Medicaid expansion. Data Sources. Person-level data from the National Health Interview Survey (1998-2010) is used to measure insurance coverage and related outcomes for low-income parents. Using state identifiers available at the National Center for Health Statistics Research Data Center, we attach state Medicaid eligibility thresholds for parents collected from a variety of sources to NHIS observations. Study Design. We use changes in the Medicaid eligibility threshold for parents within states over time to identify the effects of changes in eligibility on low-income parents. Principal Findings. We find that expanding Medicaid eligibility increases insurance coverage, reduces unmet needs due to cost and OOP spending, and improves mental health status among low-income parents. Moreover, our findings suggest that uninsured populations in states not currently participating in the ACA Medicaid expansion would experience even larger improvements in coverage and related outcomes than those in participating states if they chose to expand eligibility. Conclusions. The ACA Medicaid expansion has the potential to improve a wide variety of coverage, access, financial, and health outcomes for uninsured parents in states that choose to expand coverage. Key Words. Medicaid, access to care, financial burden, mental health, parents, As of May 2015, 28 states and the District of Columbia had chosen to implement the Medicaid expansion allowed by the Affordable Care Act (ACA). The expansion is expected to [...]

Objective. To assess the coverage effects of California's 2011 Low-Income Health Program (LIHP), enacted as an 'early expansion' under the Affordable Care Act (ACA), and to demonstrate the feasibility of using Census data to measure county-level coverage changes. Data Sources/Study Setting. 2008-2012 American Community Survey (ACS). The sample contained California adults ages 19-64 years (n = 237,876) and children 0-18 years (n = 113,159) with incomes below 200 percent of the federal poverty level. Study Design. Differences-in-differences analysis comparing public coverage, private insurance, and the uninsured rate in counties that expanded the LIHP in 2011 versus California counties not expanding during this time. Additional analyses tested for heterogeneous impacts of the LIHP and spillover effects on children. Principal Findings. Compared to nonexpansion counties, public coverage for adults increased by 1.8 percentage points (p = .02) in expanding counties, while the uninsured rate declined by 2.1 percentage points (p = .01). There was no significant change in private coverage. Public coverage gains were largest for Latinos and those with limited English proficiency. The expansion produced a positive spillover effect on children's Medicaid enrollment. Conclusions. California's 2011 expansion produced significant increases in public coverage for low-income individuals, particularly Latinos. Substate coverage analyses with the ACS can add valuable detail to future assessments of the ACA. Key Words. Medicaid, health reform, uninsured, disparities, state policies, The Affordable Care Act's (ACA) major coverage expansions are underway. Evidence from several surveys shows large declines in the uninsured rate, particularly in states that expanded Medicaid beginning in 2014 [...]

Objective. To examine the willingness to accept new Medicaid patients among certified rural health clinics (RHCs) and other nonsafety net rural providers. Data Sources. Experimental (audit) data from a 10-state study of primary care practices, county-level information from the Area Health Resource File, and RHC information from the Center for Medicare and Medicaid Services. Study Design. We generate appointment rates for rural and nonrural areas by patient-payer type (private, Medicaid, self-pay) to then motivate our focus on within-rural variation by clinic type (RHC vs. non-RHC). Multivariate linear models test for statistical differences and assess the estimates' sensitivity to the inclusion of control variables. Data Collection. The primary data are from a large field study. Principal Findings. Approximately 80 percent of Medicaid callers receive an appointment in rural areas--a rate more than 20 percentage points greater than non-rural areas. Importantly, within rural areas, RHCs offer appointments to prospective Medicaid patients nearly 95 percent of the time, while the rural (nonsafety net) non-RHC Medicaid rate is less than 75 percent. Measured differences are robust to covariate adjustment. Conclusions. Our study suggests that RHC status, with its alternative payment model, is strongly associated with new Medicaid patient acceptance. Altering RHC financial incentives may have consequences for rural Medicaid enrollees. Key Words. Medicaid, rural health care, rural health clinics, primary care, audit methodology, Ensuring a sufficient supply of health care providers in rural areas has been a long-standing health policy issue at the local and national levels (Newhouse 1990; Ricketts 2000; Rabinowitz et [...]

Objective. To estimate the impact of Express Lane Eligible (ELE) implementation on Medicaid/CHIP enrollment in eight states. Data Sources/Study Setting. 2007 to 2011 data from the Statistical Enrollment Data System (SEDS) on Medicaid/CHIP enrollment. Study Design. We estimate difference-in-difference equations, with quarter and state fixed effects. The key independent variable is an indicator for whether the state had ELE in place in the given quarter, allowing the experience of statistically matched non-ELE states to serve as a formal counterfactual against which to assess the changes in the eight ELE states. The model also controls for time-varying economic and policy factors within each state. Data Collection/Extraction Methods. We obtained SEDS enrollment data from CMS. Principal Findings. Across model specifications, the ELE effects on Medicaid enrollment among children were consistently positive, ranging between 4.0 and 7.3 percent, with most estimates statistically significant at the 5 percent level. We also find that ELE increased combined Medicaid/CHIP enrollment. Conclusions. Our results imply that ELE has been an effective way for states to increase enrollment and retention among children eligible for Medicaid/CHIP. These results also imply that ELE-like policies could improve take-up of subsidized coverage under the ACA. Key Words. Evaluation design and research, health economics, program evaluation, state health policies, Express Lane Eligiblity, Medicaid, Nearly 4.0 million uninsured children are eligible for Medicaid or the Children's Health Insurance Program (CHIP) (Kenney, Anderson, and Lynch 2013). Prior research attributes nonparticipation in Medicaid and CHIP, through [...]